ERIC G. COMSTOCK, M.D., P.A.
This patient was referred to a methadone maintenance treatment program (MMTP) for possible methadone maintenance treatment by a friend who was also a patient at the MMTP. During initial screening on February 10th, the patient was found to have a long history of polydrug abuse with a remote history of abuse of cocaine, methamphetamine, amphetamines, barbiturates, and a current history of abuse of Vicodin 10 to 15 pills per day; street methadone for three years, when available; cannabis for 13 years; benzodiazepines (identified as Xanax) three times daily for five years; and hallucinogens. His current history of opiate drug use was sufficient to meet the State and Federal criteria for admission to methadone maintenance treatment. The pre-treatment admission urinalysis revealed the presence of methadone, opiates and alprazolam. The patient reported two previous episodes of drug overdose, one requiring hospital admission to a psychiatric clinic, which he characterized as “just trying to get high.” His family history revealed current addiction of mother, father and sisters to Vicodin. Prescribed medications by his personal physician at the time of admission included Xanax and Lexapro for anxiety and depression.
On February 13th, the patient was examined by the clinic physician who confirmed a diagnosis of opiate drug dependence and initiated treatment with methadone. In the course of her examination, she identified risk factors of morbid obesity, possible sleep apnea, and asthma since childhood. Review of prescription medication history for several years prior to admission revealed a progressive increase in frequency of use of bronchodilator inhalers during the several months immediately prior to admission to methadone treatment, sometimes several times a day. Physical examination by the clinic physician revealed diffuse wheezes in both lung fields and a body weight in excess of 370 pounds.
Considering the risk factors of morbid obesity and currently active asthma, our standard protocol which involves step-wise increase of methadone administered as necessary to control the discomfort of opiate withdrawal was modified to very conservative dosages of methadone. As indicated in the attached records, the first dose was 30 mg on February 13th, and the last dose was 80 mg administered on February 25th, with one take-out dose of 80 mg for February 26th. Throughout the titration interval as called for by the protocol, the patient was seen daily by a counselor and by the program nurse with face-to-face and telephone contact with the program physician. Between the initiation of the first dose on February 13th, and the last dose (80 mg) administered on February 25th, the patient persisted with complaints of uncontrolled withdrawal and continued to maintain that the dose was inadequate in preventing withdrawal discomfort. The patient was found dead at home on February 27th.
Postmortem examination was performed by the Medical Examiner’s Office with postmortem findings consistent with pulmonary edema. Postmortem laboratory testing revealed a plasma methadone concentration of 0.51 mg/L with no detectable methadone metabolites. The Medical Examiner opined death due to accidental methadone overdose.
When adjusted for body weight, the dosages of methadone administered to this patient which provided inadequate control of his withdrawal discomfort were very conservative. The dose of 80 mg in a patient with a body weight in excess of 370 pounds would be expected to result in a blood methadone concentration of 0.1 mg/L (see Wolff, 1991, attached), or one-fifth of the concentration present at the time of postmortem examination. The concentration of 0.51 mg/L could not be achieved with the methadone dosage administered or dispensed to this patient by the clinic and could only have occurred with non-prescribed supplementation with methadone available from the street. A whole blood concentration of methadone of 0.51 mg/L is equivalent to
0.6 mg/L of serum.
Eric G. Comstock, M.D.